Health-related quality of life after prostate brachytherapy

Minimal channel GreenLight photovaporization before permanent implant prostate brachytherapy for patients with obstructive symptoms: Technically feasible and safe

PURPOSE

Brachytherapy (BrT) is a standard treatment for low-risk to favorable-intermediate-risk prostate cancer but is a relative contraindication for patients with obstructive symptoms. We aimed to assess the feasibility and urinary toxicity of a minimal photovaporization (mPVP) before implantation.

MATERIALS AND METHODS

Between 04/2009 and 08/2016, 50 patients candidates for BrT but with International Prostate Symptom Score (IPSS)>15, uroflowmetry <15 mL/s, obstructive prostate or large median lobe underwent a mPVP (GreenLight Laser) at least 6 weeks (median 8.5) before permanent seed implantation (loose seeds, ¹²⁵I, 160 Gy).

RESULTS

Two patients (4%) did not have sufficient improvement and did not undergo BrT, although it would have been possible at 3 months. For the 48 (96%) other patients, at the baseline, mean IPSS was 15.5 (±5.3), vs. 8.6 (±4.4) after mPVP (p = 1 × 10^-6), and uroflowmetry 11.7 mL/s (±4), vs. 17.4 (±5.4) (p = 1.4 × 10^-5). We did not experience any difficulty for BrT. Mean IPSS did not significantly increase 1, 3, or 6 months after BrT. With a median followup of 60 months [30-120], (92% assessed at last followup), only 4 patients (4/48 = 8.3%) experienced urinary retention and 5 (10.4%) needed surgery for urinary toxicity. In addition, only 2 patients (4%) needed medical treatment at last followup. Considering the 8 patients with de novo incontinence at 1 year, only 2 (4%) had persistent mild symptoms at last followup (36 months) (ICS1-2).

CONCLUSIONS

These results suggest that a two-step approach with an mPVP at least 6 weeks before BrT is feasible, with no excessive urinary toxicity, and may be a good strategy for obstructive patients seeking BrT.

Recto-urethral fistula following brachytherapy for localized prostate cancer

OBJECTIVE

The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development.

METHOD

A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded.

RESULTS

Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified.

CONCLUSION

The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.